Awake arteriovenous fistula creation with transverse pectoral nerve block 1 (PECS-1) and supraclavicular block

Advantages of regional anesthesia (RA) for fistula surgery include vasodilation, higher fistula blood flow and reduction in: maturation time, reoperation rate, opioid consumption, length of hospital stay, infection rates, bleeding and early thrombosis. In cadavers, the authors studied separate contribution of each injection in sagittal and transverse PECS-1 and in PECS-2 blocks, observing that the deep injection in PECS-2 (between pectoral minor and serratus muscles) and the sagittal approach PECS-1 block injection did not reach ICBN and axillary compartment, unlike the transverse PECS-1 medial-to-lateral injection. Given that maximum local anesthetic dose must be reduced in end-stage renal disease patients, and that in our experience PECS-1 needs lower volume (13 ml) for reaching the axilla compared to SIPB and PECS-2, we decided to use PECS-1 block with the transverse approach in order to more accurately and more safely reach the axillary compartment as axillary dissection was planned. [...]we find it technically easier to see and reach the plane between pectoral muscles in PECS-1 than the plane between pectoral minor and serratus muscles in PECS-2.